Duke University Health System, Durham, North Carolina (Drs Engel and Granger); Duke University Hospital, Durham, North Carolina (Drs Meyer and Reynolds and Ms Bhandari); Duke Regional Hospital, Durham, North Carolina (Dr McNeil); Duke Raleigh Hospital, Raleigh, North Carolina (Dr Hicks); and Duke University School of Nursing, Durham, North Carolina (Drs Hatch, Granger, and Reynolds).
Qual Manag Health Care. 2023;32(3):189-196. doi: 10.1097/QMH.0000000000000375. Epub 2022 Nov 5.
Central line-associated bloodstream infections (CLABSIs) are a common, preventable healthcare-associated infection. In our 3-hospital health system, CLABSI rates in non-intensive care unit (ICU) settings were above the internal target rate of zero. A robust quality improvement (QI) project to reduce non-ICU CLABSIs was undertaken by a team of Doctor of Nursing Practice (DNP)-prepared nurse leaders enrolled in a post-DNP Quality Implementation Scholars program and 2 QI experts. Based on a review of the literature and local root cause analyses, the QI team implemented the evidence-based practice of using 2% chlorhexidine gluconate (CHG) cloths for daily bathing for non-ICU patients with a central line.
A pre-post-design was used for this QI study. CHG bathing was implemented using multifaceted educational strategies that included an e-learning module, printed educational materials, educational outreach, engagement of unit-based CLABSI champions, and an electronic reminder in the electronic health record. Generalized linear mixed-effects models were used to assess the change in CLABSI rates before and after implementation of CHG bathing. CLABSI rates were also tracked using statistical process control (SPC) charts to monitor stability over time. CHG bathing documentation compliance was audited as a process measure. These audit data were provided to unit-based leadership (nurse managers and clinical team leaders) on a monthly basis. A Qualtrics survey was also disseminated to nursing leadership to evaluate their satisfaction with the CHG bathing implementation processes.
Thirty-four non-ICU settings participated in the QI study, including general medical/surgical units and specialty areas (oncology, neurosciences, cardiac, orthopedic, and pediatrics). While the change in CLABSI rates after the intervention was not statistically significant ( b = -0.35, P = .15), there was a clinically significant CLABSI rate reduction of 22.8%. Monitoring the SPC charts demonstrated that CLABSI rates remained stable after the intervention at all 3 hospitals as well as the health system. CHG bathing documentation compliance increased system-wide from 77% (January 2020) to 94% (February 2021). Overall, nurse leaders were satisfied with the CHG bathing implementation process.
To sustain this practice change in non-ICU settings, booster sessions will be completed at least on an annual basis. This study provides further support for using CHG cloths for daily patient bathing in the non-ICU setting.
中心静脉相关血流感染（CLABSIs）是一种常见的、可预防的医疗保健相关感染。在我们的 3 家医院医疗系统中，非重症监护病房（ICU）环境中的 CLABSI 发生率高于内部零目标率。一个由接受过护理实践博士（DNP）培训的护士领导组成的团队，以及 2 名质量改进（QI）专家，参与了一项减少非 ICU CLABSI 的强大质量改进（QI）项目。该团队在审查文献和当地根本原因分析的基础上，实施了一项基于证据的实践，即对带有中央导管的非 ICU 患者使用 2%葡萄糖酸氯己定（CHG）布进行日常沐浴。
本 QI 研究采用前后设计。CHG 沐浴采用多方面的教育策略实施，包括电子学习模块、印刷教育材料、教育外展、在单位设立 CLABSI 冠军，以及在电子病历中设置电子提醒。使用广义线性混合效应模型评估 CHG 沐浴实施前后 CLABSI 发生率的变化。还使用统计过程控制（SPC）图表跟踪 CLABSI 率，以监测随时间的稳定性。CHG 沐浴文件记录合规性作为过程措施进行审核。这些审核数据每月提供给单位领导（护士经理和临床团队领导）。还向护理领导分发了一份 Qualtrics 调查，以评估他们对 CHG 沐浴实施过程的满意度。
34 个非 ICU 环境参与了 QI 研究，包括普通内科/外科病房和专科领域（肿瘤、神经科学、心脏、骨科和儿科）。虽然干预后 CLABSI 率的变化没有统计学意义（b=-0.35，P=.15），但 CLABSI 率确实显著降低了 22.8%。监测 SPC 图表表明，干预后所有 3 家医院以及整个医疗系统的 CLABSI 率均保持稳定。CHG 沐浴文件记录的合规性从 2020 年 1 月的 77%提高到 2021 年 2 月的 94%。总体而言，护理领导对 CHG 沐浴实施过程感到满意。
为了在非 ICU 环境中维持这一实践改变，将至少每年完成强化课程。这项研究进一步支持在非 ICU 环境中使用 CHG 布对患者进行日常沐浴。
